全程唤醒麻醉下脑功能区病变切除手术:技术方法及初步结果

Resection of eloquent brain area lesion under all-course awake anesthesia:technical notes and initial results

目的探讨无人工气道全程唤醒麻醉下脑功能区病变切除手术方法及其临床意义。方法 47例脑功能区病变病人均在无人工气道全程唤醒麻醉下开颅,采用头皮神经阻滞、切口和硬脑膜浸润麻醉,经神经导航和(或)术中超声定位病灶,直接皮质电刺激(DES)定位脑功能区皮质和皮质下结构,进行最大范围安全切除病变。结果所有病人在手术过程中获得安全、可靠的监控麻醉,病变全切除30例(63.8%),次全切除11例(23.4%),部分切除6例(12.8%)。术后新发短暂性神经功能障碍28例(59.6%),其中术后1个月内恢复至术前水平26例,遗留严重神经功能障碍2例,1例因放射冠区梗死而引起严重瘫痪,1例因放疗后期脑积水、肿瘤脊髓转移而病情恶化。结论无人工气道全程唤醒麻醉开颅手术能够避免全麻-唤醒-全麻时在拔除喉罩过程中出现的颅内压增高等风险,能根据手术需要随时唤醒病人,较好地配合手术。应用全程唤醒麻醉手术可做到最大限度地切除脑功能区病变和保护脑功能,是脑功能区病变手术的一种唤醒麻醉新方法。

Objective To explore the surgical method and clinical significance of eloquent brain area lesion resection using all-course awake craniotomy under monitored anesthesia care without artificial airway.Methods Forty-seven patients with eloquent brain area lesion obtained maximal safe resection using all-course awake craniotomy under monitored anesthesia care without artificial airway.Scalp nerve block,incision and dural infiltration anesthesia were performed in all the patients.The lesions were localized by neuronavigation and（or） intra-operative ultrasound,and the functional cortex and sub-cortical structures were figured out by cortical direct electrical stimulation（DES）.Results All the patients received safe and reliable monitored anesthesia care during the over-all operative procedures.Total lesion resection was achieved in 30 patients（63.8%）,subtotal resection in 11（23.4%） and partial resection in 6（12.8%）.The new transient neurological deficits occurred in 28 patients（59.6%） after the operation,of whom 26 returned to baseline nerve function within 1 month,only 2 left severe neurological deficits.One patient suffered severe paralysis due to infarction of the corona radiata,another deteriorated due to hydrocephalus and spinal cord metastasis after radiotherapy at the later stage.Conclusions All-course awake craniotomy under monitored anesthesia care without artificial airway can avoid the risks of increasing the intracranial pressure and so on during pulling out the laryngeal mask in traditional awake craniotomy（asleep-awake-asleep）.The patients may be awaked at any time and cooperates well in the whole surgical process.All-course awake craniotomy might be a new method in ensuring maximal safe resection and optimal functional preservation for patients with lesion in the eloquent brain area.